Unit Culture and the Leader’s Task
I have discussed the importance of small unit leadership to achieve operational success and considered several tasks the leader needs to accomplish to create a successful unit. But three recent conversations caused me to think again about the critical role of unit culture in providing good clinical care. All three conversations revolved around dialysis units, but the lessons are universally applicable.
The first conversation was with a patient who was just back from having spent a month at another unit out of state while on vacation. When I spoke to him on my rounds he said: “It sure is good to be home. I did not know how much better it was here than other places. The staff here actually talk to you. The staff where I was barely said anything to me and didn’t even seem to be talking to each other.”
The second conversation was reported to me by the administrator. We have recently moved into a larger facility and have had rapid growth in the patient population, so we have had to supplement our regular team with “travelers.” One of the travelers had asked to meet with the administrator. Expecting a complaint or a resignation, she was surprised when the traveler said: “I just wanted you to know this is the first place I have worked where the staff did not take of their PPE as soon as the nurse manager left the floor.”
The third conversation was with the new nurse manager, who has had experience supervising many different units. I asked her for first impressions after her second day on the job. She replied: “It is refreshing to work someplace where people actually put the patients first and take care of each other and the patients as a team.”
I have never heard of a medical organization that didn’t claim to put patients first and don’t expect I ever will. But I do think there are many medical organizations that have not done the hard thinking needed to make that goal a reality. There are many things the leader must tend to, but the one which counts the most is culture. Without denying the reality of the economic pressures facing medical organizations, I want to propose that it has never been more urgent to figure out how to make patient care the central focus of our organizations. How do we create a culture where doing the right thing for the patient has priority over all the other competing priorities?
Since culture takes time to create and even more time and effort to change, if an organization does not have a working definition of what good patient care looks like and how it is done, then survival is problematic. There is no time for delay. But all organizations need to be intentional about protecting and nurturing their commitment to patient care. Maintaining a positive, patient-oriented culture that supports doing the right thing the right way is essential. This is the central task of leaders today.
So, what makes a “good” culture? It may be useful to consider the example I used with my leadership team: speed limits. There are some people who drive the speed limit because that is what the sign says. Others drive the speed limit only if they think there is a radar detector in the immediate area. But I have been places like interstates around Atlanta and Dallas, where driving the posted speed limit would be suicidal because everyone else is going 20 miles per hour faster. In those places the rule of “going with the flow” prevails. A good culture, then, is one where people align their behaviors with the “best demonstrated practices,” and do what they do because they believe it the right thing to do. “Going with the flow” means doing things the way they are supposed to be done. It doesn’t mean behaving differently when no one is trying to catch them. I like to think of the good culture as one that is internally motivated, which I usually call “craftsmanship.” A craftsman does the best work possible, even in places where no one can see it, because he/she knows what was there.
What should the leader be doing to create that kind of craftsman culture? First and foremost, the leader must behave the way he/she wants the staff to behave. Is patient care really the main priority of the leader? But, you may say, today’s economic challenges are so severe the leader must attend to the organization’s survival and that should be the first objective. An older colleague used to say the ultimate disservice to our patients was to go broke. But he meant we had to do the best patient care we could with the resources we had available, not cut back on patient care to make our financial goals. Some years ago, General Motors chose a finance man who had never been involved with car-building as their CEO. They thought of themselves as a financial giant not a car company. It took a few years, but GM found itself failing because people would not buy their cars. I don’t want to stretch the analogy, but a healthcare organization that thinks of itself as “a major employer” or the “driver of the local economy” rather than as a “good place to receive medical care” is on the road to ruin.
Second, the leader must help the team shape its “way we do things around here” so when processes are adjusted and made more efficient they are always done with an eye on the impact such changes will have on patients. This is not to say the patient is always right. Sometimes patients want things that are not really in their best interests. In such cases, it is the leader’s job to explain the reasons behind the policies as best as possible, but also to take the heat when patients complain.
A practical example may help illustrate this point. Several years ago, I became convinced that rapid ultrafiltration during dialysis contributed to reduced survival on dialysis, so I decided to limit the rate of ultrafiltration to 12 ml/kg body weight/hour. Some staff did not think this was a good idea as they knew getting the patient back to dry weight was important for keeping them out of the hospital. Patients objected because it meant either longer time on dialysis or extra treatments if they gained too much weight. It took more than six months and a lot of griping before everyone adapted to the “new” way. Was it worth it? I can’t say that it has made any real difference— clinically it was a wash. On the other hand, CMS has instituted a similar rule so at least we have already have the change stress behind us.
Third, the leader needs to make sure to recognize the efforts of staff which promote the goal of good patient care. Every dialysis unit has a both a formal and an informal clinical leader as well as an informal patient leader. The senior leader needs to make sure all of them are helping promote the clinical goals of the unit. The leader who thinks it begins and ends with himself/herself is doomed to fail.
So, is your culture patient-centered? How do you know? Fortunately, I have had these three recent conversations providing feedback that our culture is patient-centered—it is not just a delusion on my part. But, as I pointed out to the team, we must be intentional about maintaining the culture as it is the driver of our clinical and financial performance. It is also clear that many sister units are in trouble for whatever reason. Feedback from patients and staff suggest they are “patient-centered” in name only. Do you know where your unit culture really is?
8 July 2018
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